Sunday, June 13, 2010

Suppose you were on the leadership team of a 9.2 million member, $45 billion health insurance plan that had enrolled 80,000 persons with asthma, 11,000 with chronic heart failure and 225,000 with diabetes? Well, if you were leading TRICARE (the health insurance program for members of the military and their dependents), you would have had those persons enrolled in disease management. Fortunately for Disease Management Care Blog readers, the leadership didn't stop there: they also used standard research methodologies to assess whether the taxpayers were getting their money's worth AND submitted their results for peer review in the American Journal of Managed Care.

TRICARE has three regional “managed care support contractors” (MCSCs) that each provide disease management services (MCSCs). TRICARE forwards the names of patients with high rates of medical service utilization to the MCSCs who, in turn, contact the patients for participation in disease management. Patients can agree to receive “personalized telephonic counseling and educational mailings” or just mailings or choose to opt out entirely. If patients agree, their intervention includes a 40-50 minute baseline telephonic assessment, monthly follow-up calls to set/review care goals, additional educational mailings, newsletters and emails. Depending on the MCSC, patients can be graduated either after 12 months or after they've met their educational goals.

73,156 patients were contacted over the two years leading up to September 2008. Approximately 9000 opted out, 4700 were only in the program for 6 months and others lost TRICARE eligibility or were excluded because of end stage renal disease or HIV. That left 57,490 (about 23,000 with asthma, 4000 with heart failure and 29,000 with diabetes) for the outcomes analysis.

A control cohort using claims data from October ’04 to Sept ’05 of “comparable” patients with asthma, heart failure and diabetes populations was then fashioned to help the researchers better isolate the impact of the disease management programs. There were slight differences – the DM populations had slightly worse Charlson Comorbidity Index scores, higher rates of ambulatory visits as well as lower rates of ER and inpatient days.

As you might expect, all 6 groups of patients (the three intervention groups and the three control cohorts) experienced a pre-post decrease in claims expense. However, the patients in disease management experienced a bigger drop, which was calculated on an adjusted basis to from $152 for heart failure (which was not statistically significant) to $783 for diabetes (p < .05) to $832 for asthma (p < .05).

Patients with asthma also appeared to be more likely to get spirometry (but NOT controller medications), patients with heart failure were more likely to be on life-saving beta blocker and ACE inhibitor medications and patients with diabetes were more likely to get A1c, retinal and urine testing) – all of which were also statistically significant. Finally, patient surveys were littered with “agree” and “strongly agree” answers to surveys asking about the disease management programs’ effectiveness.

Bottom line? The total cost of disease management from September 2006 to September 2008 was $22.7 million. Cumulative gross savings was $28.5 million, with a return on investment (ROI) of 1.26. The DMCB believes that is not only statistically significant, it's quite financially significant.

While the canard that disease management “doesn’t save money” continues to stalk the hallways of academics, policy makers and regulators like a zombie that refuses to die, there is an emerging body of literature showing that disease management has evolved considerably from its early days. This study, conducted in a commercial setting involving millions of members, showed how other leaders of insurance plans can save some serious money.

Last but not least, this is a way for taxpayers to save some serious health care money. Hopefully the leadership in the Obama Administration will take note of this good news.

2 comments:

Anonymous
said...

The key to TRICARE saving money with this program was limiting the size of the program and targeting DM sevices at the highest utilizers. Enrolling everyone with the diagnoses in question into the DM program would almost certainly have been a money loser.

Good point. That was implied in the article when it was noted that TRICARE provided the regional entities the lists of patients with highest utilization.

There's been other work in that area: it turns out that the return on investment goes DOWN as a program signs up MORE patients. The trick is to go after the patients with higher risk that can also be modified.

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About Jaan Sidorov MD, MHSA, FACP

While his web persona has been described as a "blogvocateur," Dr. Sidorov has wide range of knowledge about the medical home, condition management, population-based health care and managed care that is only exceeded by his modesty. He has been quoted by the Wall Street Journal, Consumer Reports and NPR’s All Things Considered.
He has over 20 years experience in primary care, disease management and population based care coordination. He is a primary care general internist and former Medical Director at Geisinger Health Plan.
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